Restoring the Patient-Doctor Relationship in Medicare

Don W. Printz, MD
Article Type: 
President's Page
Fall 1996
Volume Number: 
Issue Number: 

We in AAPS are dedicated to the principle that the best medicine is practiced when the patient is in charge, with the physician acting as his ally. And nothing empowers the patient more than being able to direct the money being spent for his own medical care. Patients need to know the cost, but also they should profit, from both a personal and economic standpoint, by being an intelligent consumer.

Any time a third party is interposed between physician and patient, there is loss of privacy and freedom.

In Medicare, the interference has so far been marginal. You still have your free choice of physician. We did have a rather substantial change in the way physicians are paid under Part B in the mid to late 1980s. The way Medicare now pays me may not have any relationship to the cost of performing a service. In other words, Medicare has interfered with the pricing mechanism. For example, HCFA has claimed that it cannot directly determine what my office overhead should be. Therefore, they calculate it based on what as 1200-square foot apartment would cost in Atlanta. People who get a notice from Medicare saying that their doctor has exceeded the limiting charge don’t realize the arcane way in which the charge was derived.

A second method of interfering with the patient-physician relationship is the notice that Medicare used to send out to patients whose physicians  did not accept assignment. It said that if your physician had accepted assignment, the cost of your visit would have been “X.” They enclosed a list of physicians who accept assignment.

Many patients don’t realize that “accepting assignment” simply means having HCFA send the physician the check directly. Some of us consider this almost immoral. It completely divorces our patients from any knowledge of what their medical care costs.

One reform that could be accomplished immediately is to stop the system of assignment. Then the check would always come to you as a patient, and you would then pay the physician. I am not worried about my patient’s honesty. I might lose a little, but if HCFA would send me an explanation of benefits when they send a check to you, that would put the relationship where it should be. You are my boss, and I am your ally, and we work together on medical care.

The patient is even further removed from control [of his/her medical care] under managed care. Think about who is doing the managing. And who profits from it? The largest managed care organization keeps 23.5% of its revenues from your premiums as profits and administrative expenses. Worse, the gatekeeper (primary physician) may profit from withholding laboratory tests and specialty referrals. Under these circumstances, the doctor no longer has the patient’s best interests at heart.

In the extreme case, the veterinary ethic replaces the Oath of Hippocrates. The payer decides whether the patient is worth spending the money. In Britain, the Chancellor of the Exchequer decided that patients over the age of 55 were not worth dialyzing, and 1800 people died within the year.

How do we restore the patient-physician relationship? One way is to allow you to put aside, in pre-tax dollars, the funds to pay everyday expenses, and to restore insurance as a protection against unlikely catastrophes. One suggestion is to eliminate capital gains tax on funds placed in medical savings accounts by senior citizens.

The most important thing is to make sure that you stay in charge of your medical care and that your physician not try to serve two masters.

I hope these remarks will serve as a reminder that you as patients, more than any other group, are physicians’ greatest allies in preventing third-party intrusion into medical care.

In addition, keeping the patient in charge of the dollar flow is the most effective means of preventing fraud; people become extremely careful when spending their own money.

For this reason, we have challenged other organized medical groups to join AAPS in what we believe is a most effective way to lesson fraud: Outlaw the assignment of benefits under Medicare. Furthermore, we propose to let those 65 and over use two powerful tools to take charge of their medical care: MSAs and the ability to contract privately for medical services, whether they have elected to participate in Part B or not. Only with the patient in full control can the patient-doctor relationship be preserved.

 Dr. Printz is the President of the Association of American Physicians and Surgeons. He is a dermatologist in Lilburn, Georgia. This President’s Page is based upon his timeless oration to the Seniors Coalition upon his ascension as President-elect of the AAPS in 1995.

Originally published in the Medical Sentinel 1996;1(3):6. Copyright ©1996 Association of American Physicians and Surgeons (AAPS).


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